Proctectomy with total mesorectal excision (TME) is the gold standard for rectal cancer surgical management, as it offers optimal oncologic results. However, this radical procedure is impaired by significant drawbacks, including temporary diverting stoma, risk of permanent stoma, high risk of postoperative morbidity, and long-term risk of postoperative bowel, urinary, and sexual disorders. These results led some authors to define "early rectal cancer" in an attempt to propose alternative strategies such as local excision in order to avoid radical surgery. Indeed, local surgery does not involve diverting stoma, has the advantage of sphincter-preservation even for very low rectal tumors, is associated with very good short-term results and accounts for a nearly nil long-term risk of bowel dysfunction or urogenital disorders. However, local excision, as opposed to TME, does not allow lymph node resection and staging. Its indication has therefore been the subject of debate. Finally, the recent description of organ preservation strategies, which concept lies in the avoidance of radical surgery, has recently been the subject of a high number of publications, including some poor-prognosis early rectal cancer. Recently, early rectal cancer has therefore become an intense field of research. In this review, we will assess described strategies and controversies regarding early rectal cancer management.